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A strength-based approach to adolescent risk reduction Naomi A. Schapiro, RN, PhD (c), CPNP Clinical Professor, UCSF School of Nursing October 20, 2011.

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Presentation on theme: "A strength-based approach to adolescent risk reduction Naomi A. Schapiro, RN, PhD (c), CPNP Clinical Professor, UCSF School of Nursing October 20, 2011."— Presentation transcript:

1 A strength-based approach to adolescent risk reduction Naomi A. Schapiro, RN, PhD (c), CPNP Clinical Professor, UCSF School of Nursing October 20, 2011

2 Traditional Approaches to Risk Reduction Risk Assessment Anticipatory guidance Health Belief Model: – Perceived Severity of condition – Perceived Susceptibility to Condition – Perceived Benefits of Taking Action – Perceived Costs of Taking Action Outweighed by Benefits

3 Traditional Approaches to Risk Reduction Health Belief Model: – Perceived Severity of condition – Perceived Susceptibility to Condition – Perceived Benefits of Taking Action – Perceived Costs of Taking Action Outweighed by Benefits Prompts & Reminders Support Self-Efficacy

4 Traditional Approaches to Adolescent Risk Reduction Risk Assessment – Deficit model Anticipatory guidance Health Belief Model: – Perceived Severity of condition – Perceived Susceptibility to Condition – Perceived Benefits of Taking Action Leading causes of death & illness in teens related to risk behaviors Accidents Suicide Homicide Drug & alcohol use Sexual activity Increasing prevalence of mental health conditions

5 Traditional Approaches to Adolescent Risk Reduction Risk Assessment – Deficit model Anticipatory guidance Health Belief Model: – Perceived Severity of condition – Perceived Susceptibility to Condition – Perceived Benefits of Taking Action Psychosocial Screen (HEADSSS) – problem oriented Home Education Activities Drugs/Diet Sexuality & Abuse Suicide/Depression Safety

6 Sexual Behaviors in US http://www.nationalsexstudy.indiana.edu

7 Teen Sexual Behaviors Chlamydia Rates (2008) – 15-19 yrs – 1956/100,000 – 20-24 yrs – 2084/100,000 Teen pregnancy rates (2006) – Overall 7.1% California has highest numbers Highest rates in New Mexico, Nevada, Arizona,Texas, Mississippi – Steady decline from 1990 to 2005, rise in 2006

8 How does knowledge translate to condom use? http://www.nationalsexstudy.indiana.edu

9 How does the Health Belief Model intersect with Adolescent Development? Teens are – present oriented – less likely to perceive personal susceptibility to adverse consequences – ambivalent about authority/messages about what they should do – eager for discussions about risky behaviors and mentoring about making their own healthy choices

10 Strength Based Approaches Elicit & acknowledge the teen’s own personal resources & context of their lives positive youth development – “orients youth toward actively seeking out and acquiring the personal, environmental, and social assets that are the ‘building blocks’ for future success.” (Duncan, 2007, doi:10.1016/j.jadohealth.2007.05.024) – Assets associated with positive transitions to adulthood & lower levels of risky behavior

11 Strength Based Approaches Youth are using their increasing cognitive and emotional/social skills to achieve these assets

12 Consistent with client-centered counseling  FRAMES Feedback of behavior Personal Responsibility for Change Advice to Change Menu of options for change Empathy for patient/situation Promote Self-efficacy Client-centered counseling (AKA Brief Intervention AKA Motivational Interviewing) – Helps client resolve own ambivalence – Help increase own confidence to change

13 Adolescent Context: Cognitive/Psychosocial Development

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15 Early adolescence (10-13) Little practical experience (taking the bus, filling a prescription) Very concrete, very present-oriented Very focused on body image, body changes Peer group very important

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17 Middle adolescence (14-16) Some ability to engage in short-term planning  but limited practical experience  dating, risk-taking behaviors Peer group activities

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19 Late adolescence (16-23) Approaching adult cognition, abilities to plan  long-term goals  life skills More independence from peer group  drinking, drug use, STDs compared w/ older adults

20 Risk-taking: is it good or bad for the teen?

21 How does driving promote – Independence – Mastery – Generosity – Belonging What are developmental concerns related to risk & asset building?

22 Concept of Risk Biopsychosocial view (Jessor, 1991) Outcomes of behaviors a. social, legal as well as biomedical b. positive as well as negative outcomes

23 Role of Risk in Adolescent Development 1.Gaining peer acceptance and respect [Connection] 2. Establishing autonomy from parents [Independence]

24 Role of Risk in Adolescent Development 3. Repudiating norms and values of conventional authority [Independence] 4. Coping with anxiety, frustration 5. Marking transition out of childhood to more adult status [Mastery] How does risk intersect with Generosity?

25 Screening for Assets & Risks - SSHADESS Strengths School Home Activities & Employment Drugs & Diet Emotions Sexuality, Sexual Abuse Safety – youth violence & accidents VERY important – can’t cover today within time frame

26 Strengths Highlighting to frame the rest of the discussion – How does youth describe self? – How much prompting is needed? – Are you surprised by the answers? How does this change your approach? Questions: – How would you describe your personal strengths? – If you were in a job interview, what would you tell a boss about why should be hired? – What do your friends say about you?

27 Strengths Jasmine is 16 years old, new to your clinic. She spent most of last year in residential or day treatment for multiple psychiatric issues Recently living with mother – was in foster care GPA 1.4 last year Has “friends with benefits” (male) – minimal condom use When asked to describe her skills and best personality characteristics, Jasmine enthusiastically answers: great voice, great friend, loves to read, good concentration

28 School - Strengths How does school build: Mastery Independence Generosity Belonging

29 School - Strengths Disconnection from school often a precursor to other risky behaviors (especially middle school) What strengths does Jasmine have that could help her succeed in school?

30 School – Strengths/Risks Jasmine had a GPA last year of 1.4 She changed schools twice in the last year – Foster care/instability despite AB 490 protection She is upset that her current school doesn’t have a chorus

31 Emotions Beyond depression & anxiety – asking about moods in general – What have your moods been like lately? – Elicits more anger, frustration, positive descriptions Encourages a richer conversation Do need to ask about suicidal ideation/attempts

32 Emotions – depression/suicide In the past 12 months – 13.8% of HS students seriously considered suicide – 6.9% attempted suicide – 2% made attempt requiring medical attention 33.9% of young women felt sad/hopeless  2 weeks in last year 19.1% of young men Young men – 10.5% Young women – 17.4% – White – 16.1% – Latina – 20.2% – Black – 18.1% > 50% of all suicides (all ages) committed with firearms in US 2009 YRBSS

33 Emotions & Bullying/Rejection 19.9% of HS students were bullied on school site in the last 12 months Recent news reports of suicides – teens bullied because of sexual orientation/gender issues & at least 1 suicide of a bully http://www.itgetsbetterproject.com/ http://colorlines.com/archives/2010/10/our_love_is_newsw orthy_too.html

34 Suicide and Sexual Orientation  risk for gay male youth, bisexual youth Risk assoc w/ rejection by family, violence, being homeless – Even small  in family acceptance can  risk – Risks also related to school bullying http://familyproject.sfsu.edu/home

35 Suicide Prevention Youth Development Approach Traditional approaches – Assess risk – Ask youth to make a no suicide contract – Refer Some evidence that contracts were not protective Youth development – Safety Assess risk Refer – Ask youth to make a safety plan tailored to levels of suicidality “If I feel X, I will do Y” – Ask youth to make a hope box Mementos, objects instill hope, remind of connections, effectiveness Joiner, 2011

36 Jasmine - Emotions Reluctant to answer questions “Read my chart” – in therapy 3x a week Denies current suicidal ideation/plans, + history of past attempts X 2 Describes moods as “happy at home and with friends, annoyed at school”

37 Sexual Activity vs. Sexuality A normal part of life vs. an area of risk? – Research comparing parental approaches in Netherlands vs. US A strength-based approach to promoting healthy sexuality – A – Autonomy – B - Build good relationships – C – Foster connectedness – D – Diversity & Disparities http://people.umass.edu/schalet/pubs.html

38 Sexuality – Youth Development Jasmine has not been tested recently for STIs When asked about her experience/knowledge about condoms, she replies : “Well if I could get them, I would use them!” Cites almost daily psych appointments, lack of access A youth development approach Asking permission to discuss – Can we talk about… Assessing knowledge before delivering health ed messages – What do you know about…. Sexuality in the context of relationships & connection

39 Safer sex & relationships Condom use declines as intimate relationships last longer More condom use with side partners What is the meaning of condom use within an intimate romantic relationship?

40 Sexual Orientation in the 21st century – Current generation of youth less willing to be “labeled” in a category – Sexual orientation for women may be more fluid than previously thought – Among 15-19 yr olds, 4.5% of men, 10.6% of women have had same sex contact (CDC, 2005)

41 Sexual Activity: Are Gender Identity & Sexual Orientation Problems? Safety? – Schools – families Disclosure? Don’t reduce MSM to HIV risk (youth development approach) Possibilities of opposite- gender partners Transgender/questioning youth may feel unsafe in all settings, few services

42 Sexual Activity Screening/Intervention Issues Past/Current Sexual Abuse – Provider must report if teen < 18 – Affects current ability to negotiate partners, safer sex – Affects comfort level w/ exams, especially pelvic exam –  incidence eating disorders (esp. bulimia) Youth Development approach: taking back control & setting boundaries – What have you done to help yourself heal? – Some survivors have difficulty negotiating safe relationships & sex after sexual abuse – how have you approached this?

43 Working with Parents Pre-adolescents (<10) – Encourage discussions re: puberty, body changes – Encourage to transmit values on sexual and drug behavior – Encourage parental monitoring of/discussion about media with child – Encourage development of hobbies, sports, skills

44 Working with Parents Early adolescence: encourage  supervision, after-school activities, involvement of other adult role models Mid-late adolescence: parent moves from disciplinarian to consultant Acknowledge the frustrations, difficulties Discuss asset building, reframe teen behaviors in asset building model

45 Working with Teens Tailor screening questions to the teen’s age, developmental level Nonjudgmental approach Warn of limits of confidentiality

46 Working with Teens Wash your hands!!

47 Harm Reduction and Teens  Delaying onset  Decreasing amount of exposure  Making the context safer  Choosing the environment  Avoiding riskier combinations  Drinking & driving  Drinking & sex

48 Harm Reduction and Teens  Protection from adverse consequences  Condoms & advance ECP  The “no fault” call home  Easy access to confidential services  Youth development & harm reduction  Involve youth in assessment of risks/safety & development of safety plans

49 Client Centered Counseling OARS Techniques – getting the adolescent talking – Open Ended Questions – Affirmations – especially important in stigmatized groups – Reflections (3 reflections to every question) Voice inflected downward Communicates “I’m listening” vs. a question – Summarize Let me see if I understand what you’ve been saying…

50 Brief Intervention/ Motivational Interview Rapport – set stage – get permission Explore ambivalence – OARS Assess readiness to change (1 to 10 or ruler scale) – Importance of change – Belief in ability to change – Strengths/barriers - “Why a 5 and not a 3?” “Why a 5 and not a 7?” Ask for a plan Wrap up

51 Crystal B., 16 y.o. CC: Here for birth control (OCs) S- describes self as friendly, sociable, caring S- 10 th grade, GPA 2.2, failed one course, unsure of goals H – lives with mother & stepfather, 2 younger sibs, gets along well, “but I don’t talk to them”

52 Crystal B., 16 y.o. A – “To be honest, I like to drink.” No organized activities at school or community D- Gets drunk every weekend, blackout X 1, occasional MJ, cigarettes, father w/ hx of alcoholism, sober X 2 yrs

53 Crystal B., 16 y.o. E- Denies suicidal ideation, attempts or depression S – Sexually active with 3 lifetime partners, +/- condom use, usually has sex when drunk, denies history of abuse

54 Crystal B., 16 y.o Safety- +/- seatbelt use (75%), no guns in home, does not ride with drunk drivers (“When we drink, we just stay overnight in one place”)

55 Crystal B., 16 y.o Strengths? Risks?

56 Crystal B., 16 y.o You screen her for STIs and pregnancy How do you want to focus your counseling? How effective would Ocs (her chosen method) be as a method of contraception? What would be a youth development way to approach this issue?

57 Crystal B., 16 y.o One week later, Crystal is called back to clinic. Her Chlamydia test is positive How can you use the disclosure of her chlamydia results as a “teachable moment”? How would you start a motivational intervention?

58 Crystal B., 16 y.o “Can we talk about….?” “What do you know about …?” “ On a scale of 1 to 10, how confident are you in your ability to use condoms?” – What keeps you from being a 7?

59 Take Home Messages Teens have strengths & can be part of the solution Teens want to talk about the same risky behaviors you are concerned about – and they want you to understand the context You can empathize with parents & encourage parent-child communication WITHOUT violating confidentiality


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